Swyer-James-MacLeod Syndrome is a rare acquired pulmonary disorder that develops secondary to infectious etiologies in early childhood. Patients who are affected have the potential of developing perioperative respiratory complications. While regional anaesthetic techniques are often performed as adjuncts to general anaesthesia, there is less data on breast operations being done solely under regional anaesthesia. We herein describe a patient with Swyer-James-MacLeod Syndrome who underwent breast lesion wide excision under combined paravertebral and pectoral nerves block, supplemented with propofol infusion for sedation. Choice of blocks was decided upon based on knowledge on the anatomy. Sole regional anaesthetic techniques have been the safest approach in some circumstances and should always be considered in patients who are of high risk under general anaesthesia.
Swyer-James-MacLeod Syndrome (SJMS) is a rare, acquired post-infectious condition characterised by emphysematous changes or bronchiectasis which may lead to fibrosis to cause pulmonary capillary bed destruction. Patients with severe lung disease presenting for anaesthesia are a challenge because intraoperative and postoperative respiratory complications are more common in them, and these may lead to prolonged hospital stay and increased mortality. Regional anaesthetic techniques are often used adjunctively for breast surgeries under general anaesthesia (GA), but there are limited reports on breast surgeries done solely under regional anaesthesia (RA). We describe a patient with SJMS who successfully underwent breast surgery under regional anaesthesia.
Written consent was obtained from the patient for publication of this case report.
The patient is a 51-year-old female with a history of Swyer-James-MacLeod Syndrome (SJMS) who required stereotactic hook-wire localization, wide excision of left breast micro calcifications. Her only surgical history was an uneventful laparoscopic bilateral salpingo-oophorectomy earlier in the same year performed under combined spinal-epidural, for which she required postoperative intensive care monitoring. Although she was NYHA class 2, her recent lung function test was grossly abnormal: FEV1 1.04 L (46% predicted), FVC 1.97 L (76% predicted) and FEV/FVC ratio 53%. Her chest X-ray showed changes congruent with her diagnosis: hypoplastic, bronchiectatic left lung and bronchial wall thickening in the right lung (
She was planned for surgery under regional anaesthesia. Single shot paravertebral, medial and lateral pectoral nerve blocks were performed under conscious sedation with intravenous midazolam 1mg and fentanyl 50 mcg. She was first positioned prone and left T3 and T4 paravertebral spaces were located with ultrasound (
the sagittal plane using out of plane technique. 100 mg lignocaine (5 mcg/ml adrenaline) and 50 mg ropivacaine in 10 ml were administered to each level. She was then positioned supine for medial and lateral pectoral nerve block with 8 ml of 200 mg lignocaine (5 mcg/ml adrenaline) under in-plane ultrasound guidance in the infraclavicular area.
Sedation was started at patient’s request with propofol target controlled infusion, Schneider mode at effect site concentration of 1.8 ng/ml. A 3 cm radial skin incision was made 18 minutes after the completion of regional anaesthesia. Planned wide excision proceeded smoothly with excellent surgical condition. Total surgical time was 20 minutes and patient recovered well enough for same-day discharge.
Swyer-James-MacLeod Syndrome (SJMS), which was first described in 1953 by Swyer and James, and further detailed by MacLeod, is a rare acquired condition secondary to viral bronchiolitis and pneumonitis in childhood [
The anaesthetic considerations must be individualised, depending on the severity of lung involvement, comorbidities as well as type of surgical procedure. In severe cases, such as that in our patient, anaesthetic management parallels that of patients with obstructive lung disease [
In view of her underlying SJMS, regional anaesthesia was performed to avoid potential postoperative respiratory complications. An incision was to be made at the 0700 position of the lower inner quadrant of the left breast. The combination of single shot paravertebral block at T3 and T4 levels, as well as medial and lateral pectoral nerve blocks was chosen based on the knowledge of the anatomy of the breast. The breast is mainly innervated by the anterolateral and anteromedial branches of the thoracic intercostal nerves corresponding to T3 - T5 and these are being targeted by the paravertebral blocks. Supraclavicular nerves from the lower fibers of the cervical plexus provide innervation to the upper and lateral portions of the breast. Researchers believe sensation to the nipple derives largely from the lateral cutaneous branch of T4 [
A brief literature search of the MEDLINE database via Pubmed was carried out to review the types of RA performed for breast surgery. Articles were included (
First Author (year) | Patient indication | Surgical indication | Type of block | Outcome | Complication |
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Our presented patient | SJMS with grossly abnormal lung function test | Left lower inner quadrant lumpectomy | PVB and Pecs I block | Excellent surgical condition. Discharged on the same day. | - |
Moon EJ (2017) [ | Refusal of GA | Left breast mass for Breast-Conserving Surgery with Axillary Clearance | Pecs I and II (in combination with sedation) | Analgesic effect lasted 8 hours No post-operative nausea and vomiting (PONV) | - |
Versyck B. (2017) [ | 140 patients with breast cancer stage 1 - 3 | Mastectomy or lumpectomy with sentinel node or axillary node dissection | Pecs II block or placebo block with saline | Pecs group had significantly less pain during stay in recovery area, required significantly less postoperative opioids | - |
Hong B (2017) [ | 27-weeks parturient, with recurrent breast cancer, refused GA | Wide excision of breast mass 3 - 4 cm below the clavicle | Pecs II block and Pecto-intercostal fascial block | No intraoperative analgesics. Postoperative Visual Analogue Scale (VAS) score 1 but did not require further analgesics. | - |
Abdallah FW (2017) [ | Cohort study of 225 patients with breast cancer | Ambulatory breast cancer surgery | 3 study groups of (75 per group): pectoralis, serratus block and conventional opioid-based analgesia | Pec and SPB associated with, reduced intraoperative fentanyl requirements, expedited recovery room discharge, reduced post-operative opioid use and PONV compared to control | - |
Kim H (2017) [ | Refusal of GA | Excision of breast giant fibroadenoma | Pecs I, Pecs II and internal intercostal plane block | No intraoperative opioid needed. No postoperative pain | - |
Takahashi H (2017) [ | 72 years old, breast cancer at 1 o’clock position of the right breast | Modified radical mastectomy with sentinel node dissection | Complete ante-thoracic (medial, inferior, lateral) block, with sedation using propofol and remifentanil 0.1 mcg/kg/min | No postoperative analgesics. | - |
Patel SY (2017) [ | 65 year old with ductal carcinoma-in-situ and mammary dysplasia, history of severe PONV | Unilateral mastectomy and TRAM flap reconstruction without axillary lymph node dissection | Pecs I and II, unilateral abdominal TAP block done before GA | NRS 4 - 5/10 on the side not blocked mild to moderate nausea 0 - 48 hrs RA lasted 24 hrs | - |
Cata JP (2016) [ | Retrospective study of 792 non-metastatic breast cancer to evaluate if use of PVB prolongs their survival | Mastectomy | 198 given PVB, remainder treated with opioid based analgesia | Significantly lower intraoperative fentanyl consumption No significant change in recurrence-free survival | - |
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Hards M (2016) [ | Retrospective study of 27 breast cancer patients | Mastectomy | 16 had serratus block; 11 had wound infiltration | No patients with SPB had severe pain in recovery or POD 1 2 patients who had wound infiltration had severe pain in recovery, and 3 patients on POD1 | - |
Bonomi S (2016) [ | Breast cancer patients | Implant-based breast reconstructions | Bilateral Pecs block, with GA | Eliminated need for post-operative opoid no PONV lower mean VAS score throughout inpatient stay | - |
Fallatah S (2016) [ | 40 patients with unilateral breast cancer | Unilateral lumpectomy and axillary lymph nodes dissection | 20 patients received peroperative unilateral PVB from T2-6; 20 patients received postoperative PCA morphine; both with GA | Significantly lower pain scores, shorter hospital stay, higher satisfaction score, and less PONV in patients who had PVB | 2 patients who had PVB had inadvertent vascular puncture and one with pain at the site of injection that continued beyond a month |
Wolf O (2016) [ | RCT involving 74 breast cancer patients | Prosthetic breast reconstruction | PVB with GA or GA alone | Significantly less intraoperative and postoperative opioid consumption Less antiemetic medication | - |
Khemka R (2016) [ | 2 patients with unilateral breast malignancy | breast conservation surgery with dissection of the axillary nodes followed by reconstruction using a LD pedicle flap | Pecs I block and serratus anterior plane block with GA | No intraoperative opioid. 1 had 6 mg morphine 0 - 48 hs. The other had 4 mg of morphine 0 - 48 hs | - |
Fusco P (2016) [ | 78 year old severe respiratory insufficiency for pulmonary fibrosis | Radical mastectomy and axillary dissection | Serratus plane block, PECS I block, parasternal LA injections | Complete anaesthesia of mammary and axillary regions. No opioids first 24 hs of surgery | - |
Shah A (2015) [ | Retrospective review involving 132 patients | Implant-based breast reconstruction | Intercostal nerve blockade | Significant reduction in length of stay, consumption of intravenous morphine and increased cost-savings | - |
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Sundarathiti P (2015) [ | RCT involving 70 breast cancer patients | Unilateral mastectomy surgery with axillary dissection | GA or PVB via catheter and injections at 3 different levels | Analgesic consumption, post-operative pain scores significantly greater in patients with GA | - |
Kulkarni K (2013) [ | 40 ASA I and II patients with breast cancer | Radical mastectomies | Cervical epidural anaesthesia with either 10 mls of 0.25% bupivacaine or 10 mls of 0.375% ropivacaine | Similar onset of sensory block Significant increase in mean motor blockade score, time to achieve complete blockade and time to grade I motor recovery for patients who received bupivacaine | Respiratory distress in 2 patients requiring GA with intubation |
Coopey SB (2013) [ | Retrospective review of breast cancer patients | Mastectomies with immediate reconstructions | PVB | Significantly less mean length of stay, shorter mean time to conversion to oral narcotics, less incidence of PONV in PVB group | - |
Li NL (2011) [ | 40 breast cancer patients | Unilateral breast surgery | GA or (GA and PVB) | Significantly lower pain scores at all time points, incidences of PONV, doses of postoperative analgesics and narcotics and higher Quality of Recovery scores in PVB group | - |
Moller JF (2007) [ | RCT involving 88 breast cancer patients | Breast tumour resection or mastectomy with lymph node biopsy | GA and paravertebral injections with either 0.5% ropivacaine or saline | Postoperative consumption of IV fentanyl and number of patients who reported pain >3 on NRS were significantly less in the Ropivacaine group | - |
Singh AP (2006) [ | 50 ASA 1 or 2 breast cancer patients | Modified radical mastectomies | Cervical epidural anaesthesia with 10 mls of 1% lignocaine followed by 0.125% bupivacaine through epidural catheter | No clinically significant variations in perioperative pulse and respiratory rate No fall in mean arterial blood pressure during operation | One case where the procedure was terminated due to accidental dura puncture. |
Exadaktylos AK (2006) [ | Retrospective study of 129 patients with breast cancer | Mastectomy and axillary clearance | 50 patients had PVB with GA; 79 patients had GA with morphine analgesia | Recurrence- and metastasis-free survival was significantly higher in the PVB patients | - |
Kolawole IK (2006) [ | 1. 55 years old patient with recurrent left breast tumour with lung metastasis complicated by pleural effusion and pneumonia 2. 60 years old left breast mass with widespread lung metastasis | Palliative simple mastectomy | Intercostal nerves block at thoracic levels 2 - 7; infraclavicular approach to superficial cervical plexus; subcutaneous infiltration in midline to block contralateral intercostal fibres | 1) pain-free for 5 hours 2) Uneventful postoperative course | - |
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Kairaluoma PM (2004) [ | 60 breast cancer patients | Breast resection or mastectomy with and without associated axillary dissection | GA and PVB with bupivacaine or saline | Significantly less post-operative opioid medication, less pain after 24 h, less PONV in the bupivacaine group | One patient had bilateral convulsions right after bupivacaine injection |
Stamatiou G (2004) [ | 24 years old, 14 weeks of gestation, with left breast tumour | Wide local excision of tumour and lymph node dissection | T1-T7 thoracic paravertebral block and superficial cervical nerve block | Tolerated 65 min of operation under sedation with propofol infusion Total analgesic requirement was 12 mg morphine and 5 g paracetamol for the first 48 hs | - |
Buckenmaier CC 3rd (2002) [ | 72 year old patient with HOCM, emphysema on home oxygen therapy | Left partial mastectomy with axillary dissection for infiltrating ductal carcinoma | Left paravertebral nerve blocks at thoracic levels 1 - 6; left superficial cervical plexus block | Pain free and opioid free on day of operation 4 mg of IV morphine on POD1 Discharged pain free subsequently | Hypotension, attribulated to sedation and possibly hypovolemia from fasting; resolved after fluid challenge |
D'Ercole FJ (1999) [ | 38 year old, 29 weeks of gestation with a 10 cm left breast mass | Left modified radical mastectomy with axillary dissection | Left paravertebral nerve blocks at T1-T6 | Tolerated procedure Oral non-opioid analgesia 18 h after neural blockade Discharged on POD2 | - |
Atanassoff PG (1994) [ | RCT involving 48 ASA I and II patients | lumpectomy | 3 groups of patients receiving intercostal nerve blockade of T3-6 unilaterally with either 1.5% or 2% lidocaine or 0.5% bupivacaine. 4th group was control who received GA | Significantly higher postoperative pain scores in control group. Number of women requiring post-operative analgesia, total amount of analgesics given during 24 hs post operatively were significantly lower in RA group | - |
Several randomised controlled trials [
R. Blanco, who developed the Pecs I and II blocks, came up with the description of the serratus plane block (SPB), which blocks primarily the thoracic intercostal nerves and provides complete analgesia to the lateral part of the thorax [
Regional techniques have frequently been performed as an adjunct to GA, but there have been less data on it being given as the sole anaesthesia for breast surgery. The use of a thoracic paravertebral block at T1-3 levels with 3 ml solution of 0.75% ropivacaine at each level was described in a left quadrantectomy with axillary lymph node dissection for infiltrating ductal carcinoma in a patient who is at a late stage of amyotrophic lateral sclerosis. No other analgesia was given during the 110-min surgery and for 34 hours post-surgery [
RA, either used alone or as an adjunct to GA, can also be recommended for well patients for the benefit it carries. Basic sciences studies and a retrospective review have suggested that breast cancer patients had better cancer outcomes if they received paravertebral blocks with GA compared to those who had received GA alone [
Regional anaesthesia has proven to be the safest approach in circumstances where GA would have carried a much higher risk. A patient with Eisenmenger’s syndrome had surgical resection of a carotid body tumour done successfully under continuous cervical plexus block and remifentanil infusion, avoiding GA and its associated haemodynamic complications [
Apart from the patient’s medical condition and choice when considering method of anaesthesia, other practical issues include patient comfort and the ability to provide ideal operating conditions. RA can be combined with sedation to improve intra-operative patient comfort. However, gentle surgical manipulation is required and this may not be well-received by all surgeons. Consequences of potential complications resulting from RA have to be taken into consideration. In this particular patient, it would have been disastrous if a pneumothorax were to result from PVB in the only functional lung.
Regional block with sedation is a feasible anaesthetic option for patients going for breast surgeries and this can reduce perioperative respiratory risks dramatically in patients with severe lung pathology. In addition, it may also be recommended to well patients as RA may improve other aspects of postoperative recovery, such as better pain control, lower incidence of PONV, shorter length of stay, which may all indirectly increase cost savings. However, there are other considerations such as surgeon’s and patient’s acceptability before making RA the default technique for breast operations.
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Xing, J.Y. and Thong, S.Y. (2018) Case Report of a Patient with Swyer-James-MacLeod Syndrome Undergoing Breast Surgery under Regional Anaesthesia and Review of Literature. Open Journal of Anesthesiology, 8, 66-79. https://doi.org/10.4236/ojanes.2018.83007